Authorisation Please use capital letters

As a director/beneficial shareholder of the company named above I understand that: • the company has made an application to have its Construction Industry Scheme payments paid gross under Section 63, Finance Act 2004 • HM Revenue & Customs (HMRC) have made a direction that in dealing with this application they will consider whether the directors/beneficial shareholders have complied with the conditions set out at Paragraph 4, Part 1, Schedule 11, Finance Act 2004.

If HMRC are of the opinion that I have not complied with all the conditions set out at Paragraph 4 Part 1, Schedule 11, Finance Act 2004, I authorise HMRC to disclose this to the company secretary.

I understand that HMRC may refer to any of my failures to fulfil the conditions in any appeal proceedings before the Tribunal. I authorise HMRC to do this.

Director’s/beneficial shareholder’s name

Director’s/beneficial shareholder’s Unique Tax Reference (UTR)

National Insurance number

Put ‘X’ in one or both boxes, whichever applies

I am a director and/or a beneficial shareholder of the company named above

Signature

Date DD MM YYYY